Giant Cell Arteritis Increased Risk Of Aortic Dissection?

• Research article
• Open Access
• Published: 07 January 2022

Symptomatic aortitis at giant cell arteritis diagnosis: a prognostic factor of aortic result

• Gauthier Blonz^{ane  na1},
• Geoffrey Urbanski²,
• Cédric Landron³,
• Jérôme Connault^one,
• Christian Lavigne²,
• Pascal Roblot^three,
• François Maillot⁴,
• Alexandra Audemard-Verger⁴,
• Mathieu Artifoniⁱ,
• Cécile Durant^one,
• Béatrice Guyomarch⁵,
• Mohamed Hamidou¹,
• Julie Magnant⁴,
• Christian Agard^one &
• French Study Group for Large Vessel Vasculitis (GEFA)

Arthritis Research & Therapy volume 23, Article number:14 (2021) Cite this commodity

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Abstract

Background

Giant cell arteritis (GCA) is frequently associated with aortic involvement that is likely to cause life-threatening structural complications (aneurysm, autopsy). Few studies accept investigated the occurrence of these complications, and no predictive factor has been identified so far. The aim of this report was to investigate factors associated with the risk of aortic complications in a cohort of GCA aortitis.

Methods

Data of all patients managed with aortitis (CT or 18 FDG PET) at the diagnosis of GCA in five hospitals from May 1998 and April 2022 were retrospectively nerveless. Clinical features were compared according to the presence of aortitis symptoms. The predictive factors of occurrence or aggravation of aortic structural abnormalities were investigated.

Results

One hundred and seventy-one patients with GCA aortitis were included; 55 patients (32%) had symptoms of aortitis (dorsal/lumbar/abdominal pain, aortic insufficiency) at diagnosis. The median follow-upwards was 38 months. Aortic complications occurred later on a median fourth dimension of 32 months. There were 19 new aortic aneurysms or complications of aneurysm and 5 dissections. Survival without aortic complexity was significantly unlike between the symptomatic and non-symptomatic groups (Log rank, p = 0.0003). In multivariate analysis the presence of aortitis symptoms at diagnosis (Hour 6.64 [one.95, 22.6] p = 0.002) and GCA relapse (Hr iii.62 [1.2, ten.9] p = 0.02) were factors associated with the occurrence of aortic complications.

Conclusion

In this study, the presence of aortitis symptoms at the diagnosis of GCA aortitis and GCA relapse were contained predictive factors of occurrence of aortic complications during follow-up.

Introduction

Giant jail cell arteritis (GCA) is the most frequent systemic vasculitis, in which aortitis is present at diagnosis in xl to 65% of cases [1, two]. The screening for aortitis is now consensually included in international guidelines for all patients diagnosed with GCA [iii, 4]. Aortic interest is not systematically evaluated, although it is a potentially life threatening condition due to aortic complications such as aortic aneurysms and dissection [five,vi,7,8,9]. Aortic complications may be nowadays at the time of diagnosis but may likewise occur many years after the diagnosis of GCA aortitis [9].

There are few data on the prognostic value of aortic involvement in GCA. Overall mortality does not announced to be increased [x, 11]. In contrast, in a cohort study of 204 GCA patients with large vessel interest, survival was impaired in patients with aortic aneurysm or dissection [12]. Moreover, large vessel impairment was reported to be associated to higher GCA relapse rates [10, 11, 13, fourteen].

To date, there are no articulate information on the link between clinical presentation of aortitis, at the fourth dimension of diagnosis of GCA, and the prognosis of the disease. The aim of this study was to evaluate clinical presentation and outcome of GCA-related aortitis.

Methods

Patients

This study included patients diagnosed with GCA between May 1998 and Apr 2022 from v hospitals in western French republic. Data were collected from medical records. Each patient had to meet at least three American Higher of Rheumatology criteria for the diagnosis of GCA [15]; or be over 50-year-old age with a biological inflammatory syndrome and with the presence of an aortic inflammatory illness on imaging exam (CT, MRI, PET) [3]; and have an aortic interest at diagnosis defined by the following: a circumferential aortic parietal thickening > 2.2 mm on CT/MRI, and/or a grade 2 or iii parietal aortic hypermetabolism on PET [3, 16].

Symptomatic aortitis was defined by the presence 1 month before or at GCA diagnosis of ane or more than of the following signs: recent, less 2 months, occurrence of chest, dorsal, lumbar, or abdominal pain; or unknown aortic insufficiency with recent dyspnea highlighted at aortitis diagnosis. This signs were unexplained by any other crusade than aortitis (musculoskeletal degenerative disease, atherosclerotic or other aortic disease).

Ethics

This written report accept received ethics board approving by GNEDS (Groupe Nantais d'Ethique et de Soins) the local ideals committee of the Academy Hospital of Nantes (20200219). Each patient included in this written report received written data, and no patient objected to this written report.

Definition of study end-points

Aortic complexity was defined by the occurrence, at least 1 month after initial imaging of the aorta, of a new aortic structural aberration (aneurysm: thoracic aortic diameter > 4 cm or abdominal aorta diameter > three cm; or aortic autopsy), or the demand for aortic surgery in response to a threatening structural abnormality (aortic dissection, progression of the aneurysm reaching a critical size, or aortic insufficiency).

Peripheral vascular consequence was defined by the occurrence, at least one calendar month subsequently initial imaging, of one of the post-obit complication: limb ischemia, mesenteric or renal ischemia, myocardial ischemia, or ischemic stroke.

GCA relapse was defined past the concomitant reappearance of GCA-related clinical manifestations and a biological inflammatory syndrome (CRP ≥ 15 mg/l), or the reappearance of a biological inflammatory syndrome with inflammatory arterial parietal changes on CT, MRI or PET [17,xviii,xix,20].

Patients with not-symptomatic aortitis (noS-Ao) at diagnosis were compared to patients with symptomatic aortitis at diagnosis (South-Ao).

Only radiographically monitored patients were included in the multivariate study and survival assay.

Statistical analysis

Qualitative values were expressed in terms of numbers and percentages. The mean comparisons were made using t test. Frequency comparisons were made by a chi-squared exam or the Fisher examination co-ordinate to the statistical headcount. Prognostic factors associated with aortic complication were evaluated with Cox models. Hazard ratios (HR) with their 95%CI has been estimated as clan measures. Variables with p < 0.05 in univariate model and all the variables already known to be misreckoning factors were candidate variables for multivariate model. Survival curves were estimated with their 95% confidence interval (95%CI) using Kaplan-Maier estimators, and Log rank tests were performed to compare aortic complication gratuitous survival between groups.

Results

Characteristics of the 171 patients with GCA aortitis

This study included 171 cases of GCA with aortitis at diagnosis, whose characteristics are described in Table i. Aortic CT was performed at baseline in 142 patients (83%), both CT and PET in 67 (39%), PET in 92 (54%), and aortic MRI in 12 (7%). Ascending thoracic aorta was involved in 123 cases (72%), aortic arch in 107 (63%), descending thoracic aorta in 110 (64%), and abdominal aorta in 95 (56%). Thoracic aortic aneurysm at GCA diagnosis and intestinal aortic aneurysm was present respectively in 13 patients (23.6%) in S-Ao, ix (seven.viii%) in noS-Ao (p = 0.009), 6 (10.9%) in S-Ao, and iv (3.iv%) in noS-Ao (p = 0.08).

Table ane Population characteristics and comparison between symptomatic and not-symptomatic aortitis patients

Full size tabular array

Aortitis was symptomatic in 55 cases (32%), including 51% chest pain, 31% abdominal pain, 16% back hurting, and 35% had previously unknown aortic insufficiency with recent dyspnea.

Ten patients (five.viii%) had undergone aortic surgery for an inaugural complication: 5 Stanford-A aortic dissections (1 patient died), and five ascending thoracic aorta aneurysms (all underwent surgery because of the size of the aneurysms, of which three were also responsible for severe aortic insufficiency).

Immunosuppressive handling was introduced in eighteen.1% (n = 31) of cases (12.vii% in S-Ao and xx.vii% in noS-Ao (p = 0.20)): methotrexate in 23 cases, tocilizumab in three cases, azathioprine in 3 cases, and cyclophosphamide in 2 cases.

At least one control imaging (CT angiography, PET, or MR angiography) was performed for 98 patients: 44 (80%) of S-Ao patients and 54 (52%) of noS-Ao patients. For patients who had a control imaging during follow-up, mean duration betwixt initial and last imaging was 35.6 months (± 34.7), mean follow-up time was 34.4 months (± 30.8) for S-Ao patients and 36.five months (± 37.ix) for noS-Ao patients (p = 0.77).

Twenty-three aortic complications occurred during follow-upward (23.5% of patients with command imaging): 15 in S-Ao patients (34.1% with command imaging) and 8 in noS-Ao patients (14.eight% with command imaging) (p < 0.01); these complications do non include aortic aneurysms, dissections or surgeries that occurred at diagnosis or in the month following the diagnosis of GCA. There were 15 new aortic aneurysms, 4 disquisitional increase size of a pre-existing aneurysm requiring surgery, and iv aortic dissections: 3 (v.5%) in S-Ao and 1 (0.9%) in noS-Ao (p = 0.06).

Aortic complications occurred afterward a median delay of 27 months [2 to 101 months]. I patient died following the rupture of an abdominal aortic aneurysm that was not present at diagnosis. These aortic complications required surgery for 9 patients, while iii other had contraindications for surgery because of their health status, and 1 declined surgery. Of the 15 aortic aneurysms that occurred during the follow-up, 11 were located on the ascending thoracic aorta, and 4 on the abdominal aorta.

Vascular evolution and relapse in GCA aortitis patients

Multivariate cox model (Table 2) showed that the presence of aortitis symptoms at diagnosis (HR 6.64 [1.95, 22.6] p = 0.002) and GCA relapse (HR 3.62 [1.2, 10.9] p = 0.02) were contained factors of aortic complication.

Table 2 Univariate and multivariate Cox proportional hazards regression analyses of variables related to the occurrence of aortic complications on radiographically monitored patients (IS Immunosuppressive handling)

Full size tabular array

Survival without aortic complexity was significantly different between the symptomatic and not-symptomatic groups (Log rank, p = 0.0003) (Fig. 1).

Fig. ane

Survival without aortic complication: comparison according to the presence of aortitis symptoms at GCA diagnosis on radiographically monitored patients

Full size image

Nineteen (35%) Due south-Ao and 53 (46%) noS-Ao patients had a GCA relapse (p = 0.18); 8 (xv%) S-Ao and 21 (18%) noS-Ao patients developed subsequent peripheral vascular event (p = 0.72). Eighteen patients died during follow-upwards (2 S-Ao and 16 noS-Ao, p = 0.07). Causes of death recorded were 1 dissection of the thoracic aorta, 1 rupture of an abdominal aortic aneurysm, 5 cardiovascular causes, 3 infections, 1 cancer, and 1 severe hemorrhage.

Discussion

This nowadays report is the kickoff aimed to appraise the prognostic bear upon of symptomatic aortitis in a large cohort of GCA patients with well-documented aortitis at diagnosis.

Patients with symptomatic aortitis had significantly more than cardiovascular risk factors (smoking, hypertension) than asymptomatic patients, suggesting a potential boosted consequence leading to astringent aortic involvement. In accordance to the literature, the aorta was mostly affected in its thoracic segment, especially the ascending thoracic aorta [1, 2]. Aortic aneurysms may be nowadays at the time of diagnosis of GCA, concerning between 4 and 23% of patients [1, 2]. In our nowadays written report, exclusively including patients with well-documented aortitis, this frequency was quite high (19%). At diagnosis or during follow-up, de Boysson et al. reported the discovery of aortic aneurysms in 11% of patients with aortitis, only also in 7% of GCA patients without aortitis [11]. In this study, an aortic aneurysm or dissection was inaugural in 23.4% of patients, with a need for surgery at diagnosis in v.viii% of all patients. These data support the involvement of performing aorta imaging at diagnosis of GCA [4].

In our experience, patients with non-symptomatic aortitis received more frequently Methylprednisolone pulses. This is in function due to a higher frequency of ocular involvement in these patients. The utilise of immunosuppressive treatment during follow-up remained infrequent (18.1% of all cases) and mainly used for severe or resistant forms.

In case of aortitis, control imaging should be used to assess evolution and discover structural complications. The lack of systematic monitoring probably leads to an underestimation of the actual number of aortic complications. In the presence of aortitis, imaging at 1 and ii years from the diagnosis may be considered to assess wall inflammation and screen for aortic aneurysms; afterwards imaging can be discussed in instance of multiple relapses or corticosteroid dependence.

During GCA, possible predictive factors of aortic complication (aneurysm, autopsy) accept already been suggested: coronary artery disease and hypercholesterolemia [7, 12], arterial hypertension and PMR at diagnosis [21], and presence of aneurysms of the subclavian arteries [22], but prospective studies are lacking to assess this of import effect. In a study including 549 patients, aortic inflammation has been described equally the best predictor of aortic dilation [11]. In our own previous study, aortitis at the diagnosis of GCA was associated to higher corticosteroid dependence and college cardiovascular mortality [8].

In this study, 23.v% of patients (14.8% of noS-Ao patients and 34.ane% of S-Ao patients) adult an aortic complication after a median filibuster of 27 months, which is quite similar to the 2.5 years constitute in the historical study past Evans et al. [5]. Moreover, we plant that symptomatic aortitis at diagnosis was associated to a significantly higher adventure of developing aortic complications, with hazard ratio at half-dozen.64. The presence of aortitis symptoms could therefore reflect a disease with locally more severe inflammation that is the basis for structural damage. The interpretation of the prognosis of symptomatic aortitis must exist careful considering it also tin can be argued that advanced aortic affliction at GCA diagnosis has unfavorable prognosis due to a significant diagnostic delay or a prior aortic disease.

This study presents an original concept with the search for clinical signs of aortitis at GCA diagnosis. If these results are confirmed, imaging could aid identify patients with more than aggressive aortitis.

Our study has several limitations: with the potential data capture errors and missing data that are inherently an issue with all retrospective data collection and brusk median follow-upwardly. Although the initial dose of corticosteroid therapy was the aforementioned in both groups, tapering schedules were not standardized, and the apply of immunosuppressive therapy was not standardized. Moreover, for nearly patients, control modalities and blood pressure objectives were not clearly indicated. Only 18.1% of the accomplice were treated with additional immunosuppression despite recent EULAR recommendations [23] since this is a cohort with patients included over a long period with some patients exclusively managed with steroids. The follow-up time limited the ability to capture aortic complexity that tin can occur 5–10 years after diagnosis.

In improver, clinical signs associated with symptomatic aortitis are non-specific: hurting or dyspnea is very frequent in elderly population; however in this study, symptomatic aortitis was retained after exclusion of musculoskeletal degenerative affliction and atherosclerotic or other aortic disease that could explicate these symptoms.

Several aortic CT scans performed were non synchronized to the heart rate (limiting the assay of the ascending thoracic aorta) and some had no late arterial phase to evaluate aortic parietal contrast; follow-upwards imaging was not systematic and was performed at widely varying times.

If these information are confirmed in prospective studies, a more intensive initial treatment for symptomatic aortitis at diagnosis—with initial corticosteroid therapy combined with immunosuppressive therapy—could be evaluated.

The management of cardiovascular take a chance factors is too fundamental, including blood pressure monitoring with self-measures, a strict goal for LDL cholesterol level, smoking cessation, and regular concrete activeness.

Conclusion

Aortitis in GCA may lead to severe complications like aneurysm or dissection. Patients who have symptomatic aortitis, mainly chest and intestinal pain, at the time of diagnosis of GCA, could represent a singled-out sub-group of aortitis with more aortic aneurysm or autopsy during follow-up than patients with non-symptomatic aortitis. Prospective studies are needed to ostend our results. In society to take better care of these patients, recommendations on the frequency and modalities of aortic imaging remain to be defined.

Availability of data and materials

Data are available to request. No expiration date of data requests is currently set in one case they are made available. Access is provided after a proposal has been canonical by an independent review committee identified for this purpose and after receipt of a signed information sharing understanding. Data and documents, including the study protocol, statistical analysis programme, and clinical study report, will be provided in a secure data sharing surroundings for upwards to 2 years per proposal. For details on submitting a request, see the instructions provided at www.clinicalstudydatarequest.com.

Abbreviations

CT:

Computed tomography

GCA:

Behemothic jail cell arteritis

noS-Ao:

Non-symptomatic aortitis

PET:

Positron emission tomography

Southward-Ao:

Symptomatic aortitis

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Funding

No specific funding was received from any funding bodies in the public, commercial, or not-for-turn a profit sectors to carry out the work described in this manuscript.

Author information

Author notes

1. Olivier Espitia and Gauthier Blonz contributed equally to this work.

Affiliations

1. Department of Internal Medicine, CHU Nantes, ane place Alexis Ricordeau, 44093, Nantes, French republic

   Olivier Espitia, Gauthier Blonz, Jérôme Connault, Mathieu Artifoni, Cécile Durant, Mohamed Hamidou & Christian Agard

2. Department of Internal Medicine, CHU Angers, Angers, France

   Geoffrey Urbanski & Christian Lavigne

3. Department of Internal Medicine, CHU Poitiers, Poitiers, France

   Cédric Landron & Pascal Roblot

4. Department of Internal Medicine, CHRU Tours, Tours, France

   François Maillot, Alexandra Audemard-Verger & Julie Magnant

5. Research Department, Methodology and Biostatistics Platform, CHU Nantes, Nantes, France

   Béatrice Guyomarch

Consortia

French Written report Group for Big Vessel Vasculitis (GEFA)

Contributions

GB: acquisition of information; analysis and interpretation of data; drafting of the manuscript. GU, CL, JC, CL, PR, FM, AA, MA, CD, MH, JM: acquisition of data and critical review; BG: methodology; CA analysis and interpretation of information OE: written report concept and blueprint; conquering of data; analysis and interpretation of information; drafting of the manuscript; supervision. All authors read and approved the final manuscript.

Respective writer

Correspondence to Olivier Espitia.

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Ethics approval and consent to participate

This report accept received ethics board approval past GNEDS (Groupe Nantais d'Ethique et de Soin) the local ethics committee of the University Infirmary of Nantes (20200219).

Consent for publication

Each patient included in this study received written information and no patient objected to this study.

Competing interests

The authors accept declared no conflicts of interest.

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Espitia, O., Blonz, Grand., Urbanski, G. et al. Symptomatic aortitis at giant cell arteritis diagnosis: a prognostic factor of aortic result. Arthritis Res Ther 23, 14 (2021). https://doi.org/10.1186/s13075-020-02396-5

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• Received: 03 October 2022

• Accepted: 13 December 2022

• Published: 07 January 2022

• DOI : https://doi.org/10.1186/s13075-020-02396-five

Keywords

• Behemothic cell arteritis
• Aortitis
• Aneurysm
• Aortic dissection
• Prognosis

Giant Cell Arteritis Increased Risk Of Aortic Dissection?,

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